Subungual Hematoma, Ingrown Toenail

You could also used

#11 scalpel 18 guage needle but may need digital block

Complications:

*permanent nail deformity Infection Cautery may cause inadvertent burn causing permanent damage Functional deficits (numbness)

Post-op care:

- foot elevated 24-36 hours - analgesics for pain - change dressing in 24 hours - soak toe in warm water 2x per day - look for signs of infection

Complications

-Infection

Follow-up care:

-Small dab of abx ointment on the nail 2x daily - soaked in warm, soapy water 2-3x daily -light dressing until site closes

Contraindications

-bleeding diathesis -allergy to local anesthesia

to prevent recurrence

-low heeled shoes with room for forefoot and toes - not to trim the nails to short and trim in a flat straight across fashion

Indications

-onychocryptosis (ingrown) -onychomyosis (fungal infection of the nail) -chronic paronychia (inflammation of nail fold) -onychogryposis (deformed, curved nail bed)

Procedure:

1. Sitting/Supine 2. Document size 3. Assess for fractures 4. Treat for fracture 5. Digit soaks in antiseptic solution, wash off alcohol with sterile water or allow to dry 6. Burn small hole in the nail with microcatery or paper clip (2-3x) 7. Make 1-2 mm hole 8. Clean with alcohol wipes 9. Abx ointment and dressing

Procedure:

1. Supine 2. Scrub toe with betadine and sterile drape 3. 5mL local anesthetic into syringe 4. inject local in a ring around toe (dorsal --> plantar) 5. apply tourniquet to base of toe or use penrose drain with hemostat. 6. Partial: cut the nail lengthwise with sterile scissors or nail cutters 4-5 mm from affected fold 7. Entire: cut down the middle 8. Loosen and lift nail with narrow periosteal elevator or flat edge of scissor. 9. Separate nail from nail bed by applying upward pressure 10. Ablation 11. Dry nail bed with sterile gauze 12. apply 88% phenol solution for 3 mins 13. Neutralize with alcohol 14. remove tourniquet 15. Abx ointment to nail bed with sterile nonadherent gauze 16. wrap toe with rolled or tubular gauze 17. hard soled shoe for several days

Subungual hematoma are challenging to treat why?

BC of the inability to observe the extent of nail bed laceration.

Subungual Hematoma Define:

Injury to the nail bed of fingers and toes

Simple trauma

Results in bleeding into the space between the nail bed and fingernail

Nail bed is

Richly innervated tissue responsible for nail generation and migration

Subungual Hematoma caused by:

Simple trauma Repetitive, indirect trauma to the distal end of the nail plate

Repetitive, indirect trauma to the distal end of the nail plate

Tight fitting shoe

Silver nitrite can be used for

bleeding control

DM and PVD pts

case-by-case basis try conservative measures referral if still necessary

Artificial acrylic nails are falammable and what should be avoided

cautery

Artificial acrylic nails are flammable and what should be avoided

cautery

Contraindications

crushed or fractured nails Fracture of distal phalanx Subungual melanoma Artificial acrylic nails Hematomas >50% of nail bed

If pressure is not relieved

damage to the nail matrix and the germinal layer may occur

This damage can cause

delayed regrowth dystrophy of the nail plate

Sensory supply to great toe

digital nerves that have extensor and plantar branch

Nail plate and nail bed are supported by

distal phalanx

Conservative measures

elevation of nail plate with cotton wick soaking loose-fitting shoes trimming of nails

The size of the hematoma is not directly related to the possibility of

fracture

Which toe is usually affected

great toe *either the medial or lateral border are involved

if using a paper clip it must be held with

hemostat heat the straightened portion of the paper clip with a lighter until the tip is red hot

Nail trauma requires:

history physical examination radiography

Improper trimming of the nail results in

impingement, inflammation and infection in the surrounding and overlying skin of the nail fold.

Most frequent underlying cause

improper trimming of the nail Also improperly fitted shoes that compress toes together change of shape to nail or increased curvature of lateral edges

Pt presents with

intense pain secondary to pressure caused by the hematoma

Nails are derived from

keratinization of cells from nail matrix at proximal end of nail plate

Ingrown toenails can cause

limitation in function and mobilty

Nail plate is produced by

matrix nail bed

if permanent removal of the nail is desired

matrix of the nail bed must be ablated.

Nail plate consists of

nail root in poster nail fold fixed middle portion distal free edge

If the nail bed is not cauterized

nail will regrow and symptoms may return

What is common with ingrown toenails

pain along the margin of the toenail erythema swelling infection: pustular drainage

Notify practitioner if

pain persists change in sensation, purulent or foul-smelling drainage, fever, erythema

Drainage of the hematoma provides

pain relief and decreases the secondary pressure

Definitive treatment

partial or total removal of nail

If the nail bed is cauterized

potential still exists for regrowth and return of symptoms

Nail avulsion and phenol

prevents recurrence and regrowth

Indications:

relief from the acute pain associated with visible, painful subungual hematoma

Primary goal of treatment

relieve the pressure

Whitish nail matrix of proliferating epithelial cells grows

semilunar pattern called the lunula

if nondisplaced fracture is suspected you

splint until swelling improves *radiograph when fracture is suspected

Position during procedure

supine or sitting

inform patients that

the nail may spontaneously fall off

After the blood has drained, the pain should improve significantly, if not think

underlying fracture

Nail bed is supplied by

volar digital artery